Chronic filarial disease with lymphedema is affecting about 15 million individuals worldwide, India alone accounts for 38% of the total disease. The disease causes physical disability, psychological despair, social isolation, and loss of economic productivity to the tune of about 1.5 billion dollars annually in India alone. The global elimination of lymphatic filariasis (LF) programme has been launched in many countries. It was felt that LF, though not usually deadly, is a prime disabler both of people and of progress. Yet it is a disease that is curable with the right resources and political will. Thus under the leadership of the World Health Organization (WHO) emerged the global alliance in the year 2000 for the elimination of lymphatic filariasis (GAELF). The goal of the alliance was set to eliminate LF as a public health menace by 2020. Their strategy is, the entire population at risk in the endemic areas is to be treated with annual single dose of filaricidal drug combination of albendazole and DEC for 4-5 years to cover the life span of the adult filarial worms.

Keywords: Filariasis; Global alliance; World Health Organization

How to cite this article:Das S. Global alliance for the elimination of lymphatic filariasis. Indian J Urol 2005;21:9-11

Lymphatic filariasis (LF) is a disease of poverty. Acute attacks of adenolymphangitis cause acute morbidities of fever, pain, and swellings. Chronic filarial disease with lymphedema affecting about 15 million individuals mostly women and scrotal hydrocele in about 25 million men cause physical disability, psychological despair, social isolation, and loss of economic productivity to the tune of about 1.5 billion dollars annually in India alone.[1] With more than 1.1 billion at risk and 120 million clinically infested with filariasis in the world population, the problem of LF at hand is stupendous to say the least.[2] Consequently, this Herculean problem cannot be encountered by an individual, or institutional or even national endeavor. This battle entails a concerted international or global initiative that would be proactive, prolonged, and persistent.[3] It is therefore of universal enthusiasm that the World Health Organisation(WHO) has accepted the leadership in this foray.

Global alliance

In 1993 the international task force for disease elimination decided to add filariasis to the list of diseases earmarked for eradication or elimination and requested the endemic countries for a concerted endeavor toward this goal.[4] It was felt that LF, though not usually deadly, is a prime disabler both of people and of progress. Yet it is a disease that is curable with the right resources and political will. Thus under the leadership of the WHO emerged the global alliance in the year 2000 for the elimination of lymphatic filariasis (GAELF).[5] The goal of the alliance was set to eliminate LF as a public health menace by 2020. Even though, at the outset it seems like a daunting task, there are reasons for optimism that include: (a) biological plausibility, (b) historical precedents of elimination, (c) technological advancements in diagnostics and effective antifilarial drugs, and (d) encouraging political will and commitment. The microfilaria does not replicate in the vector mosquitoes and gain access to the dermal lymphatics through nicks and fissures in the skin rather than by inoculation into circulation, thus making overall transmission relatively less effective. There are precedents of effective elimination of filariasis in China by countrywide implementation of DEC fortified salt in diet.[6]

Recent technological advances include the field ready antigen card test for diagnosis replacing the more cumbersome night blood sampling for microfilaria.[7] In addition, we now have highly effective drugs to eliminate microfilaria and suppress the adult worms. The leadership of the GAELF has generated necessary enthusiasm and commitment of the public sector of endemic countries. The twin strategies of the GAELF in this crusade against filariasis are:

1.mass drug administration to interrupt transmission and eliminate disease and

The epidemiologic field workers would first map the prevalence and endemicity of areas in the countries by administration of antigen card test. The entire population at risk in the endemic areas then are to be treated with annual single dose filaricidal drug combination of albendazole and DEC for 4-5 years to cover the life span of the adult filarial worms. Efficacy of drug administration would be monitored by subsequent diagnostic antigen card testing.

Morbidity alleviation

It is essential to address the suffering and disability of the established clinically affected patients in tandem with the strategy of mass drug administration for disease elimination. The specific morbidities include acute attacks, lymphedema, and hydrocele. Simple inexpensive self care measures have been shown to reduce the frequency of acute adenolymphangitis attacks, improve early stage lymphedema, halt progression of lymphedema to elephantiasis and improve the overall quality of life. These measures which can be readily incorporated in the daily routine of the affected people include skin care and hygiene, elevation of the legs, range of motion exercises, and wearing protective shoes.[9] Detailed illustrated protocol of self-care measures is available in the public health centers and should be widely implemented. It is unfortunate that despite the availability of these simple yet effective tools for lymphedema management and development of several lymphedema management centers in a number of countries with excellent collaboration between the public sector and nongovernment organizations (NGO), only a small proportion of world population has paid comprehensive attention to the implementation of these measures. The GAELF has made it a priority to publicize and encourage implementation of self-care programs in the endemic countries.

Management of filarial hydrocele

Surgery remains the only therapeutic choice for hydroceles. However, this simple and relatively low-cost surgery remains beyond the means of many, if not most men in the endemic areas. There are also several nuances like the size of hydrocele and thickness of the sac that dictates some variations in hydrocele surgery. The most significant stumbling block in our endeavors is the massive number of patients in need of surgery that imposes insurmountable strain on the resources of any country. GAELF has attempted to: (a) gather a consensus recommendation from surgeons of different endemic countries regarding surgical technique and (b) establish protocols for training lower level health-care individuals to select out uncomplicated hydroceles that they can operate upon at primary level centers. The more complicated hydroceles are to be referred to secondary and tertiary centers for expert care. The whole idea is to make a dent in the large backlog of patients without compromising care. These published protocols detailing the selection criteria, set up of surgical centers, equipments, anesthesia, and surgical techniques, are made available from the WHO.[10]

Management of major lymphedema and elephantiasis

Major reconstructive surgery remains the mainstay of treatment for these unfortunate patients. Although at some of the workshops the techniques of lymphedema excision and reconstruction with or without lymphadenovenous anastomosis at tertiary centers have been discussed, at this juncture unfortunately any comprehensive coverage of this subject remains beyond the scope of activity of the GAELF. We certainly hope that promotion of established self-skin-care programs will prevent and curtail the incidence of this major disability.

Conclusion

The GAELF consisting of ministries of health of endemic countries, donor pharmaceutical companies, involved universities, governments of UK, Japan, Spain, and Italy, multiple NGOs and philanthropic organizations, is making major strides toward the goal of elimination of LF as public health menace. The success of this mission depends upon concerted implementation of the twin strategies of mass drug administration and morbidity alleviation. We would hope to continue with the strategies of GAELF against LF until this scourge of civilization is eliminated.